SummaryBackgroundStrategic purchasing has been introduced as a key strategy for solving the problems faced by insurance companies. In Iran, the government has mandated the Iran Health Insurance Organization (IHIO) to implement this strategy. However, there are serious challenges to achieving that. The present study aims to identify these challenges.MethodsIn this qualitative study, a semi‐structured interview was conducted on 27 health managers and experts at the national level. The dimensions of the A. Preker model were used to analyze the data.ResultsChallenges of strategic purchasing in the IHIO were categorized into five concepts—political economy, policy design, organizational structure, organizational environment, and management capacity; within these concepts, 22 challenges were identified.ConclusionsImproving strategic purchasing in Iran requires adopting a coherent approach and taking into account all the affecting factors. By revising some policies, and modifying and defining the rules needed to solve the infrastructural problems, the success of strategic purchasing can be obtained.

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Background One of the major reforms in the health system of any country is the financing reform. Network analysis as a practical method for investigating complex systems allows distinguishing prominent actors in the relation networks. Leading to the identification of the effective actors and key links between them, the analysis of financial networks helps policymakers to implement reformations by providing appropriate evidence. This study aimed to design and analyze the network of National Health Accounts (NHA) and the cost network in the Iran health insurance ecosystem. Methods The present study is a network analysis study based on the data from NHA, and both cost and referral rates that was conducted in 2021. Data, which was for the years 2014 to 2018 and related to NHA, was collected from the Statistical Center of Iran, and cost data and referral rates, which were both related to Basic Insurance Organizations (BIOs), were collected from statistical yearbooks. To analyze the network and identify the key actors, macro indicators, such as network size and density, and micro indicators, such as centrality indicators and the combined importance index, were used. Results In the financing of the health system in Iran, insurance organizations, as agents and sources of financing, do not have a very good position, so direct payments have become a key element in the network of NHA. Providing treatment-oriented services is quite prior. Regarded to health services, hospitals and outpatient services, such as pharmacies and physicians are the key elements of cost and referral rates respectively. Conclusion Consisting of several organizations with different insurance policies and being supervised under different ministries, Iran's health financing system lacks a coherent structure. It is suggested to create a coherent insurance system by creating a single governance system and paying more attention to health-oriented instead of treatment-oriented services. The health insurance ecosystem has become a health-oriented system to reduce the direct payments as well as cost management.

Introduction The policy-making process in health reform is challenging due to the complexity of organizations, overlapping roles, and diversity of responsibilities. The present study aims to investigate and analyze the network of actors in the Iran health insurance ecosystem regarding the laws before and after the adoption of the Universal Health Insurance (UHI). Methods The present study was done by sequential exploratory mixed method research, consisting of two distinct phases. During the qualitative phase, the actors and issues pertaining to the laws of the Iranian health insurance ecosystem from 1971 to 2021 were identified through a systematic search of the laws and regulations section of the Research Center of the Islamic Legislative Assembly website. Qualitative data was analyzed in three steps using directed content analysis. During the quantitative phase, in order to draw the communication network of the actors in Iran's health insurance ecosystem, the data related to the nodes and links of the networks was collected. The communication networks were drawn using Gephi software and the micro- and macro-indicators of network were calculated and analyzed. Results There were 245 laws and 510 articles identified in the field of health insurance in Iran from 1971 to 2021. Most of the legal comments were on financial matters and credit allocation, and the payment of premiums. The number of actors before and after the enactment of the UHI Law was 33 and 137, respectively. The Ministry of Health and Medical Education and the Iran Health Insurance Organization were found the two main actors in the network before and after the approval of this law. Conclusions Adopting a UHI Law and delegating various legal missions and tasks, often with support to the health insurance organization, have facilitated the achievement of the law objectives. However, it has created a poor governance system and a network of actors with low coherence. Based on the results of the study, it is suggested to reduce actor roles and separate them for better governance and to prevent corruption in health insurance ecosystem. Introducing knowledge and technology brokers can be effective in strengthening governance and filling the structural gaps between actors.